Personality Disorders Continued



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Personality Disorders Continued

Carolyn R. Fallahi, Ph. D.

Obsessive-Compulsive Personality Disorder


  • Similarities to Negativistic p.d. ( the old passive-aggressive p.d. lavel)

  • Common themes include ambivalent & conflicted personality dynamics that underlie presentation.

  • Ambivalence is defined as a lack of certainty over the source of reinforcement in one’s life.

  • Ambivalent individuals = conflicted over whether they should follow what others want them to do or follow their own needs and wishes.

  • “Anxious – fearful” cluster with anxiety & tension prominent symptoms.

  • OCPD: extreme rigidity, preoccupation with details & perfectionism.

  • Interpersonal relationships lacking – seen as cold, distant, & authoritarian. They have an excessive need to control others.

  • The issue with subordinate relationships.

  • Little motivation to become more flexible.

  • OCPD: avoids unwelcome thoughts or impulses & frequently distracts them by becoming unduly critical and judgmental of others.

  • Rigid, perfectionist, & restricted emotional expressivity.

  • Millon: intense ambivalence as the central feature.

Prevalence


Historically



  • Psychoanalytic theory: intense conflict during the anal stage of psychosexual development = “anal character”.

  • Kraft-Ebing: “compulsion” = constricted thought processes in individuals with severe depression. Then began to use the term to indicate hidden emotions, incessant questioning, doubtfulness, & other characteristics.

  • Anakastic (Schneider, 1923) = conceal feelings of insecurity, compensates by adopting an overly correct or scrupulous demeanor, & uses control in most relationships.

  • Kretschmer = “sensitive” personality type.

  • Kahn (1931) ambivalent tendencies = “ambitendency”.

  • Reich (1949) extreme attention to order, circumstantiality, rumination, indecision, self-doubt.


Contemporary Theories



  • Psychoanalytic: struggles over autonomy

  • Erikson (1950): gain autonomy over one’s self & environment.

  • Rado (1959) mother’s demandingness & intrusiveness into child’s bowel patterns = defiance and anger.

  • Mallinger (1984) parental rejection, authoritarian attitudes, & lack of respect for privacy.

  • Salzman (1980) & Storr (1980) pervasive threat to security.




  • Behaviorial: very little in the literature.

  • Issues with the term OCPD.

  • Turkat & Maistro (1985): learns maladaptive emotional reactions in home & emphasizes hard work & minimizes close interpersonal relationships.




  • Cognitive Theory: Beck & Freeman (1990): OCPD clear distortions in thinking = produce rigidity & perfectionism.

  • Cognitive disortions

  • Musts and shoulds




  • Interpersonal Theory: Leary (1959) OCPD style defined by actions that maintain conventionality and security.

  • Structural Analysis of Social Behavior (Benjamin, 1974): intense fears of making a mistake / being viewed as imperfect.

  • Endler & Edwards (1988)

  • Pincus & Wiggins (1990)




  • Biological perspective: limited attention

  • Issues with anxiety.

  • Clonginger’s (1987) neurobiological theory – novelty seeking, reward dependence, harm avoidance.

  • Millon & Davis (1996) limbic system.




  • Integrative Model: Millon (1996)




  • Issues with Negativistic P.D.: stubbornness, passive resistance to fulfilling routine demands, procrastination, and inefficiency. Also sullen & irritable.

Borderline Personality Disorder

Essential Symptoms:


  • Impulsivity

  • Affective Instability

  • Cognitive Symptoms

Reliability & Validity Concerns

Prevalence

Comorbidity



  • Axis I mood disorders. Is it a form of depression?

  • Gunderston & Phillips (1991)

  • Trauma research: Kolk (1987)

  • The “borderline child”

  • Remits by early middle age.

  • 15 years = 75%

  • 1/10 commits suicide.

  • Highest risk: substance abuse + borderline

  • Stone (1993) less likely to marry or have children

Historically



  • Problems with the term “borderline”

  • Adolf Stern (1938)

  • “hysteria” or “pseudo-neurotic schizophrenia”

  • unstable personality disorder or emotionally unstable personality

Contemporary Theories



  • Biological: relatives have impulse spectrum disorders and/or affective disorders.

  • No specific pattern of inheritance has been found.

  • Torgersen (1984) twin studies – no MZ-DZ differences, but numbers small.

  • Torgersen (1996) BPD large heritable component.

  • No adoption studies.

  • No identifiable biological markers yet to be found. Similar markers to depression, e.g. abnormal REM latency; serotonergic activity.

  • Soft neurological signs, e.g. limbic activity issues.

  • Siever & Davis (1991)

  • Most likely = multiple receptors & multiple subsystems associated with each NT.

  • Linehan (1993) “emotional vulnerability”.




  • Psychological Factors: psychoanalytic emphasis on early experience.

  • Large number of negative events in childhood.

  • Borderlines also report a high frequency of childhood sexual abuse, e.g. 50-70%.

  • Incest abuse with penetration.

  • Physical abuse, frequency, duration, & severity.

  • Gender issues.

  • Herman et al (1989)

  • Zanarini et al (1989)

  • Van der Kolk et al (1991) & self-mutilation

  • Separation & loss b/f 16 (51%)

  • Parental psychopathology

  • Parental bonding issues; Gunderson et al (1980)

  • Adler (1985)

  • Linehan (1993)

Narcissistic Personality Disorder



  • Normal narcissism versus pathological narcissism

  • Definition: “a pervasive pattern of grandiosity, need for admiration, & lack of empathy”

  • Associated features: vulnerable self-esteem, sensitivity, intense reactions of humiliation, emptiness or disdain to criticism or defeat, vocational problems, feelings of shame, social withdrawal.

  • Antisocial or borderline characteristics

  • High achievement, promiscuity, excessive rage, suicidal behavior.

NPD Clinical Features



  • The Arrogant Narcissist

  • The Shy Narcissist

  • NPD with Antisocial / Borderline Features

  • Comorbid Axis I = depression or dysthymia

  • Suicide

  • Affect intolerance and vulnerability

  • Discriminating behaviors: Ronningstam & Gunderston (1990) boastful & pretentious behavior; self-centered & self-referential behavior; reactions to the envy of others.

  • Morey (1998): inflated self-esteem & marked affective reactions to assaults of self-esteem; marked need for interpersonal control; hostility; lack of overtly self-destructive behaviors.

Prevalence



  • 2-22%. Gender differences?

  • Late teens & early 20s; middle age very critical.

Sociocultural Factors



  • Lash (1979)

Comorbidity



  • Dramatic cluster, e.g. histrionic, borderline, paranoid, avoidant, passive-aggressive, antisocial.

  • Bipolar patients, substance abuse, major depression, anorexia nervosa.

Differential Diagnosis

  • Antisocial p.d.

  • Borderline p.d.

  • Histrionic p.d.

  • Obsessive-Compulsive p.d.

  • Paranoid p.d.

  • Schizoid p.d.

  • Mania & hypomania


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